Updated June 29, 2023
(* indicates a newly added/updated question)
Physicians are working hard to support each other and the public during this time when our health system is under significant pressure. Our goal is to provide clear information to help guide you as you exercise professional judgement to practice in this environment. If your question is not addressed here or if you need further support beyond the information provided below, please don't hesitate to contact us.
*Are physicians able to practice outside their usual scope of practice to help address the health human resource shortages being experienced within hospitals and across the system?
Given the significant strain on the health care system due to health human resource shortages, physicians may find themselves being asked to practice outside their usual scope of practice to help address significant patient demands, particularly in hospitals.
While CPSO’s Public Health Emergencies policy would normally only apply in a declared emergency, we recognize the need to apply this policy in these similar circumstances, enabling physicians to practice outside their usual scope of practice. Canadian Medical Protective Association has similarly issued a message of support, indicating the necessity of taking these steps at this time and provided additional guidance in this regard.
As in all cases, physicians must exercise professional judgement when temporarily practising outside their usual scope of practice, and work with their health care colleagues to determine what appropriate medical care they can provide, in accordance with relevant legislation.
This exceptional approach will remain in place as long as there is a health human resource crisis.
*How can I help alleviate the pressures Ontario hospitals are facing?
It is critically important for physicians to prioritize seeing sick patients in-person whenever possible and to minimize direct patient referrals to the emergency room when the care can be safely provided in an office setting. To further support your practice, and ensure the appropriate use of emergency resources, the Ontario College of Family Physicians has developed some helpful resources.
*How do I balance providing in-person and virtual care to my patients?
Every practice is unique and finding the right balance will require judgment on the part of the physician to consider the merits of virtual vs. in-person visits and to determine which approach is in the patient’s best interest. Physicians should continue to utilize both in-person and virtual visits based on clinical need. It is critically important that the standard of care is always met, which means in many cases, care will need to be provided in-person.
Not all patients will be able to get the care they need virtually as there are limits to what can be done virtually. In-person care is essential for many conditions and some patients do not have adequate access to virtual care. For example, where patients have difficulty communicating virtually, where physical contact is necessary to provide care and services (e.g., newborn care, prenatal care, vaccine administration) and other diagnostic and therapeutic procedures (e.g., Pap smears and biopsies), or where physical assessments are necessary to make an appropriate diagnosis or treatment decision patients need to be seen in person.
As CPSO’s Virtual Care policy states, physicians must use their professional judgment to determine whether virtual care is appropriate and only provide virtual care if it is in the patient’s best interest to do so. This means only providing virtual care when the quality of care will not be compromised by the virtual modality or when the potential benefits of providing virtual care outweigh the risks to the patient. It is important to remember that the standard of care must always be met, and that the same standards apply to in-person care and to virtual care. In addition to our policy, helpful resources regarding the limits and appropriateness of using virtual care have been developed by the Ontario College of Family Physicians, Canadian Medical Protective Association, Canadian Medical Association, and the Quality Division of Ontario Health and Ontario Telemedicine Network.
*What do I do if a patient has an expired or a red and white health card?
Until further notice, the Ministry of Health has requested that health care providers continue to accept expired green photo health cards and red and white health cards from Ontario residents, provided the card belongs to the person presenting it and it passes Health Card Validation.
You can also encourage patients to renew their expired green photo health cards or update their red and white health cards to the more secure green photo health card.
As of March 31, 2023, the Ministry of Health ended the temporary Physician and Hospital Services for Uninsured Persons (PHSUP) pandemic response funding. Accordingly, if a patient does not have a valid Ontario health card, you can direct them to visit or call Service Ontario to confirm their eligibility. If a patient is not eligible and does not have any other form of health insurance coverage, the patient may obtain health services by paying for services directly or through private health insurance.
Uninsured persons continue to have limited access to the publicly funded heath care services identified by the Ministry of Health.
Pandemic-Related Practice Issues
Can I restrict in-person care to those that do not have any flu symptoms or symptoms of COVID?
No. In-person care can be provided safely by taking appropriate precautions, including screening and isolating patients, and using necessary PPE. Patients cannot be denied access to necessary in-person care based solely on having symptoms of the flu or COVID-19. Similarly, it is not appropriate to directly refer patients to emergency departments when the initial assessment or ongoing care can be safely provided in an office setting.
*The government has ended mask mandates for most settings. What does this mean for my practice?
As of June 11, 2022, all mask mandates were lifted for indoor settings with the exception of long-term care and retirement homes. Certain Ontario hospitals have also modified their mandatory masking requirements.
Although the government lifted mask mandates, the Chief Medical Officer of Health continues to encourage all Ontarians to wear masks in crowded indoor public spaces, especially those at higher risk. Physicians or health care facilities can continue to implement masking policies that ask all staff, patients and other visitors to wear a mask when in the office.
What if a patient refuses to wear a mask?
If you have a policy that asks patients to wear masks, it’s important for patients to adhere to that policy. Some patients may have health conditions that make it difficult or inhibit their ability to wear a mask. In these cases, physicians are expected to offer appropriate options to ensure care can safely be provided.
If you encounter a situation where a patient not in need of an accommodation refuses to wear a mask, explain the expectation in your practice is that a mask be worn. When deciding how to proceed, consider that in most cases in-person care can be safely provided with appropriate precautions (e.g., donning appropriate PPE, isolating patients, providing care during set times), that physicians have a duty of care where care is urgently needed, that virtual care may be an appropriate alternative, and that redirecting patients to other parts of the system may exacerbate existing and significant resource challenges.
Physicians are not expected to tolerate verbal abuse or threats of physical violence and can take appropriate steps in these instances to defer or delay non-emergent care.
*What safety precautions do I need to take when providing in-person care?
The Ministry of Health continues to provide guidance on how to safely provide care during each stage of the pandemic. The most up-to-date information can be found on the Ministry of Health's website, where guidance is provided for different sectors within the health care system.
It is important that you follow guidance provided by the province or public health officials to implement safety precautions that are designed to protect everyone. You can also inform patients about the safety precautions you have put in place to ensure compliance with these measures.
*Patients are asking me to write notes supporting a medical exemption from COVID-19 vaccines — what do I need to know?
Patients may ask you to write notes or complete forms exempting them from getting vaccinated. If you are asked by your patient to provide information supporting a medical exemption from receiving a COVID-19 vaccine, your patient must have a legitimate medical condition that would warrant an exemption.
The Government of Canada, the Ministry of Health and some public health units have provided guidance regarding contraindications for COVID-19 vaccines. The Ministry of Health’s guidance about medical exemptions can be found in the Medical Exemptions to COVID-19 Vaccination document. Additional guidance for specific allergy populations can also be found in the COVID-19 Vaccine Guidance document.
Generally speaking, there are very few acceptable medical exemptions to the COVID-19 vaccination (examples include an allergist/immunologist-confirmed severe allergy or anaphylactic reaction to a previous dose of a COVID-19 vaccine or to any of its components that cannot be mitigated, or a diagnosed episode of myocarditis/pericarditis after receipt of an mRNA vaccine).
Given the rarity of these exceptions, and in light of the fact that vaccines have been proven to be both safe and effective, any notes written for patients who qualify for a medical exemption need to clearly specify:
- the reason they cannot be vaccinated against COVID-19 (i.e., document clear medical information that supports the exemption); and
- the effective time period for the medical reason (i.e., permanent or time-limited).
While physicians are generally required to complete third party medical reports for patients when requested, the circumstances of the pandemic support physicians declining to write notes or complete forms when the patient making the request does not have a medical condition that warrants an exemption. If you find yourself in this situation, clearly and sensitively explain to your patient that you cannot provide them with a note or form, along with the reasons why.
It is also important that physicians work with their patients to manage anxieties related to the vaccine and not enable avoidance behaviour. For example, for extreme fear of needles (trypanophobia) or other cases of serious concern, responsible use of prescription medications and/or referral to psychotherapy may be available options. Overall, physicians have a responsibility to allow their patients to be properly informed about vaccines and not have those anxieties empowered by an exemption.
*What is Paxlovid? Should I be prescribing Paxlovid as a precautionary measure?
Nirmatrelvir/ritonavir (Paxlovid) is the first oral antiviral medication for COVID-19 that can prevent serious illness, if taken quickly after symptoms start.
Patients must have tested positive for COVID-19 to be considered for treatment with Paxlovid and it cannot be prescribed as a precautionary measure. Physicians must follow the criteria and guidelines developed by the Ministry of Health and OntarioMD when considering the use of Paxlovid.
Professionalism in the Use of Social Media
*What should I be thinking about as I engage on social media?
Physicians are reminded to be aware of how their actions on social media or other forms of communication could be viewed by others. Physicians must comply with the expectations set out in CPSO’s Social Media policy when using social media, and not disseminate false and misleading information. Misinformation has a negative impact on society, can erode people’s trust in physicians, and cause other significant harm which has been examined in a recent article published in eDialogue.
The policy also includes expectations physicians must comply with when sharing health-related information about a patient online. In addition to the policy, helpful guidance on the use of social media can be found in the Advice to the Profession: Social Media document.